This form is to be completed by the bullying target, witness, or person with information about an incident of bullying or school violence. It will be electronically submitted to the building principal and assistant principal. After submission, you will receive a confirmation email from Edline which will include a copy of the completed form.

(required) 1. Name (first and last):

(required) 2. Date (mm/dd/yy):

(required) 3. Reporter (you) are a:

4. If you answered "other" to #3, please identify yourself here:

(required) 5. Are you the target of the bullying or school violence that you are reporting?

Yes

No

(required) 6. Date of incident (mm/dd/yy):

7. Time of incident:

(required) 8. Person(s) being reported as targets of bullying or school violence:*please list each person's first and last name and indicate if they are a student or staff.

(required) 9. Person(s) being reported as aggressors engaged in bullying or school violence:*please list each person's first and last name and indicate if they are a student or staff.

10. Person(s) who witnessed the bullying or school violence:*please list each person's first and last name and indicate if they are a student or staff.

(required) 11. Was the incident based on any of the these characteristics? (check all that apply)

Race

Color

Nationality

Sex

Sexual orientation

Gender identity

Gender-related identity

Gender-related expression

Ancestry

Age

Religion

Physical disability

Mental disability

Order of protection status

Homeless status

Marital status

Parental status

Pregnancy

Other (complete #12)

I don't know

12. If you answered "other" to #11, please identify a characteristic not listed:

(required) 13. Student(s) were targeted for bullying in the following way(s): (check all that apply)